Deep Vein Thrombosis

1. Deep Vein Thrombosis DVT facts, statistics, and therapeutic options MICHAEL A ARATA MD INTERVENTIONAL RADIOLOGY MEMORIAL UNIVERSITY MEDICAL CENTER SAVANNAH, GEORGIA

2. DVT Overview • Prevalence • Risk Factors • Clinical Presentation • Causes of Limb Swelling • Treatment Strategies • Clinical Experience-Case Review 2

3. The Problem of DVT: Statistics • DVT occurs in approx. 2 million Americans each year. Approx 1/3 develop PE • The combined annual incidence for DVT is approximately 2.5%-5% of the adult population • DVT recurs in 5-10% of patients the year after anticoagulation • DVT recurs in 30% of patients eight years after anticoagulation • 1996 American Heart Association Scientific Statement on DVT

4. Risk Factors for DVT • Age >40 years • Cancer • Obesity • Previous or family history of DVT/PE • Recent surgery • Paralysis or immobility • Contraceptives/Hormone replacement therapy • Pregnancy • Serious illness: CHF, MI, sepsis • Coagulation disorders 4

5. DVT: Clinical Presentation • Calf pain/tenderness • Swelling • Calor, rubor • Cyanosis or pallor • Superficial venous dilatation • Loss of pulses in severe DVT 5

6. Causes of Limb Swelling: Acute • DVT • Arterial ischemia • Superficial phlebitis • Joint effusion • Hematoma • Baker’s cyst • Arthritis • Fracture • Cellulitus • Dermatitis 6

7. Causes of Limb Swelling: Chronic Post-phlebitic syndrome • Chronic venous insufficiency • Venous obstruction Other • Heart failure • RSD • Hypoproteinemia- cirrhosis • Medication 7

8. DVT Treatment Strategies: Timing Sooner is Better! • < 3 Weeks Good • < 1 Week Better • < 3 Days Best 8

9. Rationale for Early Treatment of DVT • Early treatment increases probability of maintaining normal valve function • Damaged valves lead to venous insufficiency • Decrease recurrent DVT risk • Restore normal venous flow • Clear thrombogenic substrate • Decrease risk for PE • Asymptomatic PE occurs in majority of patients with DVT 9

10. Delayed Complications: Post-Phlebitic Syndrome • Post-Phlebitic Syndrome -- spectrum symptoms seen after DVT • pain • edema • pigmentation • ulcer • Occurs in 50 to 70% cases proximal DVT • Prevalence estimated to be as high as 2 percent in the general population 10

11. Delayed Complications: Post-Phlebitic Syndrome • Post-Phlebitic Syndrome - Result of venous hypertension • Venous hypertension • Venous insufficiency- valve damage • Venous occlusion- Chronic DVT/ Scarring 11

12. DVT Treatment Strategies: Historical Standard Primary intention-Prevent PE • Anticoagulation • Heparin, Warfarin, LMWH • IVC Filter Placement • Catheter-Directed Thrombolytics • Select cases 12

13. Vascular Thrombosis • Technology has revolutionized field • Lysis/thrombectomy STD of care • MI • Acute stroke • Acute limb ischemia • Massive PE • DVT- effort thrombosis/SVC syndrome

14. Why Not LE DVT? • Large clot burden • Systemic lysis-not effective • Initial revascularization devices inadequate • Catheter directed lysis more effective • Costly-ICU stay • Poor Patient tolerance

15. Treatment Strategies: Investigational New treatments to rapidly remove thrombus: • Mechanical Thrombectomy • Physical removal of clot burden • Often used in combination with lytics • Power Pulse Spray • Accelerated thrombolysis delivered by AngioJet system 15

16. Clinical Experience: Mechanical Thrombectomy for DVT • Experience as reported by K. Kasirajan, MD • 17 patients with extensive DVT treated with AngioJet • 7 of 17 patients had <50% thrombus removal • 9 patients thrombolytics used achieving <90% thrombus removal • Conclusion: PMT with adjunctive thrombolytic is less invasive, low risk option in patients with extensive DVT • Kasirajan K, Gray B, Ouriel K, Jvasc Inter Radiol 2001 Feb;12(2):179-85 16

17. Clinical Experience: Mechanical Thrombectomy for DVT • 44 patient retrospective study • DVT- mechanical thrombectomy using AngioJet • Key Findings • 54.5% of patients received thrombolysis administered pre-AngioJet • 56.8% of patients received adjunctive thrombolysis • No major complications were related to the use of AngioJet Kasirajan K, Arata M, Swischuk S, Hunter D, Cazenave C, Rheolytic thrombectomy for management of venous thrombosis: Results of a multicenter venous registry. J Vasc Interven Radiol 2003: 14: S16 17

18. Complete (> 90% of initial thrombus removed) Partial (> 50% of initial thrombus removed) No Response Substantial (> 50% -- 90% of initial thrombus removed) Clinical Experience: Mechanical Thrombectomy for DVT • Response to AngioJet Treatment 9% 16% 50% 25% Kasirajan K, Arata M, Swischuk S, Hunter D, Cazenave C, Rheolytic thrombectomy for management of venous thrombosis: Results of a multicenter venous registry. J Vasc Interven Radiol 2003: 14: S16 18

19. Clinical Experience: Mechanical Thrombectomy for DVT • ReportedConclusions: • AngioJet Mechanical thrombectomy is a safe adjunct or alternative to thrombolysis for DVT • Debulking with AngioJet may result in elimination or reduction of lytic dose • A sufficiently powered study is warranted to assess effects Kasirajan K, Arata M, Swischuk S, Hunter D, Cazenave C, Rheolytic thrombectomy for management of venous thrombosis: Results of a multicenter venous registry. J Vasc Interven Radiol 2003: 14: S16 19

20. AngioJet® Xpeedior® 120 20

21. Clinical Experience:Power Pulse Spray • ReportedConclusions: • 25 lower extremities • Thrombolytic success 100% • Same day treatment 52% • Procedure complete after Power Pulse Spray 80% Arata M, Pappas J, Personal experience 21

22. Deep Vein Thrombosis Mechanical Thrombectomy Case Examples This program was developed for educational purposes only. The AngioJet System is not indicated for use in the venous system.

23. Initial Venogram Initial popliteal venogram demonstrating DVT Initial femoral venogram demonstrating DVT Initial iliocaval venogram demonstrating DVT IVC Filter

24. Sequential Venograms Following AngioJet Thrombectomy Sequential venograms performed following thrombectomy passes

25. Completion Venogram Completion LE venogram Completion cavogram Completion pelvic venogram

26. Deep Vein Thrombosis Power Pulse Spray Case Examples This program was developed for educational purposes only. The AngioJet System is not indicated for use in the venous system.

27. Initial Venogram Venogram demonstrating focal femoral DVT Initial thrombus

28. F/U Overnight Lysis Venogram following overnight lysis demonstrating caudal progression of DVT Venogram following overnight lysis demonstrating marked DVT progression

29. Thrombectomy Video Video of thrombectomy and PPS

30. Power Pulse Spray LE venogram following PPS demonstrating complete lysis Pelvic venogram following iliac stenting

31. Initial Venogram Initial popliteal venogram demonstrating DVT Initial femoral venogram demonstrating DVT Initial iliocaval venogram demonstrating DVT

32. Following Power Pulse Spray Completion pelvic venogram Completion popliteal venogram Completion femoral venogram

33. Summary • DVT • Major healthcare problem • Management focus- decades old • Prevent propagation • Anticoagulation • IVC filter • Revolution in vascular technology

34. Summary • Power Pulse Spray • Same day treatment-cost effective • Preliminary results superior to lysis • Potentially safer • Substantially more patient friendly